Club Forms Kindly fill out the form below. New Client Intake Form Name Date of Birth * Phone (###) ### #### Postcode Email * Occupation Company Doctor Information Doctor’s Name * Phone (###) ### #### Emergency Contact Emergency Contact Name * Insurance Do You Have Health Insurance? * Yes No If Yes Which Insurance How Did You Find Out About Our Studio? * Medical Questionaire 1. Have You Ever Or Do You Have Any Of The Following? Heart Disease Asthma Gout Cardiovascular Condition High/Low Blood Pressure Family Hx of Heart Disease Dizziness Arthritis Infectious diseases Blackouts Diabetes Fainting Epilepsy/Fits Other 2. Do You Have Any Problems/Injuries In The Follow Areas? Knees Lower Back Neck/Shoulders Hips/Pelvis Flexibility Other 3. Are you pregnant? Yes No If So, How Many Weeks 4. Are You Currently Doing Any Regular Physical Activity? Please List What And How Many Times Per Week? 5. Have You Had Surgery In The Last 5 Years, If Yes, When & What? 6. Do You Smoke, If Yes How Many Per Day, And For How Long Have You Smoked? 7. Are You On Any Medication, If Yes What And When Do You Take? * ACKNOWLEDGEMENT RELEASE AND ASSUMPTION OF RISK Warning: This is an important document, which affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand it. If you have any questions, please ask. Acknowledgment of Risks, Injury and Obligations I acknowledge that the activities I am to undertake have potential dangers and by participating in them I am exposed to certain risks. I acknowledge and understand that whilst participating in any such activities: - I may be injured physically, mentally or may die; - Any physical conditions I may have, of which I may or may not be aware of, which I may or may not have disclosed to Fire and Ice Wellness LLC or its staff, may be aggravated or worsened by my participation; - My personal property may be lost or damaged; - Other persons participating in such activities may cause me injury or may damage my property; - I may cause injury to other persons or damage their property; - The conditions in which the activities are conducted may vary without warning; - I may be injured or die or suffer damage to my property as a result of negligence or breach of contract of the Fire and Ice Wellness LLC trainer, or its agents - There may be no or inadequate facilities for treatment or transport of me if I am injured. - I assume the risk of, and the responsibility for any injury, illness, death or property resulting from my participation in any activities. Release and Indemnity to Fire and Ice Wellness LLC trainer or its agents In the consideration of the acceptance of my payment (or guest status) for participating in any activity (except to the extent that the studio or place of business may be precluded by statute) I agree to release and indemnify Fire and Ice Wellness LLC trainer and staff as follows: - I participate in the activities at my sole risk and responsibility; and - I release, indemnify and hold harmless the Fire and Ice Wellness LLC trainer and staff from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever. CLIENT AGREEMENT - Appointments will be scheduled directly through my assigned Personal Trainer and can be scheduled on days and times that are mutually agreed upon. Private personal training sessions are approximately one hour - I understand that I am expected to arrive for my appointments on time, dressed and ready to train. If I arrive late for my appointment, I understand that my training session will end at the previously scheduled time. Cancellation Policy: -I understand that appointments must be cancelled by contacting my personal trainer directly, when 24 hours of my scheduled time to avoid being charged for the full session - No show policy: I understand that if I do not show up for my scheduled training session, I will be charged for the full session. - If my personal trainer fails to contact me within 24 hours of our scheduled session, or does not show up, he/she will schedule an additional session at no cost to me. Terms and Conditions Before signing this document, I have read and acknowledged and know how it affects my legal rights. WHERE PARTICIPANT IS UNDER 18 YEARS OF AGE (Parent / Guardian to read and sign) I, (name of parent/guardian) * hereby acknowledge and agree: - I have read the whole document and understand it; - I consent to the person, named in this Acknowledgement and Release, participating in the activity; and - I am aware of the risks, dangers and obligations set out above in this Acknowledgement and Release. In consideration of the person named in the Acknowledgement and Release being accepted to participate in any activity, I agree to release and indemnify the Fitness Centre operator, its servants and agents, in the same manner and to the same effect and extent as if I were Before signing this document, I have read and acknowledged and know how it affects my legal rights. Thank you for your interest in Fire and Ice! A team member will follow up with you within 24 hours.
